Blood Smear in a Patient With Very Severe Hypertriglyceridemia

A 33-year-old Thai woman with a past history of gestational diabetes mellitus presented at the emergency department with complaints of acute epigastric pain for 6 hours. An examination revealed tachycardia, Kussmaul breathing, and tenderness at the epigastrium. She had good mental status and no neurologic deficit. The diagnosis of diabetic ketoacidosis (DKA) was confirmed by a plasma glucose level of 420 mg/dL, serum β-hydroxybutyrate level of 4.8 mmol/L, and pH level of 7.18. Severe lipidemia was noted in the blood, and a triglyceride level of 13,311 mg/dL and total cholesterol level of 1218 mg/dL were later found. Eye-ground examination revealed lipemia retinalis. There were no xanthomas or hepatosplenomegaly. A peripheral blood smear from the first day of admission showed multiple small fat droplets on the erythrocytes [Fig. 1(a); green arrow]. After treatment with intravenous insulin and rehydration, the patient's abdominal pain and DKA rapidly improved. During continuous intravenous insulin administration, the triglyceride concentrations gradually decreased to 7596 (day 2), 5280 (day 3), 3009 (day 4), and 63 (day 6) mg/dL. After the decline of hypertriglyceridemia, the fat droplets then gradually decreased. A marked decrease was observed on the fourth day of treatment [Fig. 1(b)], corresponding with the disappearance of lipemia retinalis. No signs of acute pancreatitis or hyperviscosity syndrome developed during the admission.

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Figure 1.

Wright’s stained peripheral blood smear findings. (a) Multiple lipid droplets on the erythrocytes (green arrow) were presented during the very high triglyceride levels of 13,311 mg/dL, (b) A marked decrease in lipid droplets was observed when the triglyceride levels decreased to 3009 mg/dL.

The existence of multiple small fat droplets on the erythrocytes at peripheral blood smear is a particularly important observation in patients with very severe hypertriglyceridemia. These findings emphasize the importance of a simple tool such as a peripheral blood smear for early detection of very severe hypertriglyceridemia. Like the lipemia retinalis, the fat droplets will completely resolve after reduction of triglyceride levels.

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